GW1-2021-06243_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
1.Well Con I f tion:
.� 14:RATER ZONES .
FROM TO DESCRIPTION
ft,Well Contractor©Name ,cam,
�� & ��ft
,h fL
NC Well Contactor C on Number IS.OUTER.CASING`fix mntti wells OR LINER-
FROM TO DIAMETER THICMESS MAT IALER
fL o ft in
Company Name
/� Cj Q/a 16:; %.CASIIYG.OR;TIJSIN dared-leo
2.Well Construction Permit#: b j% FROM ? ToDIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits#.e.UX.County.State,Variance,etc.) R R in
3.Weil Use(check well use): & in.
Water Supply Well: 47;SCREEN` .;
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13M al/Public 0 & fL in.
Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft. ut.
Industnal/Commercial QResidential Water Supply(shared)
a:18:.GROiLT
._. Agricultural
'On FROM I TO A'IFRIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fL >7C'�t V
Monitoring Recovery ft. fL
Injection Well:
Aquifer Recharge ®Groundwater Remediation
19.:S4ND/GRAfi'BY;'I'itCK if ble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
_.. Aquifer Test OStormwater Drainage fL fL
Experimental Technology 13 Subsidence Control fL
Geothermal(Closed Loop) Tracer 38s DRII.LIING::LOG.*uKh admtieoal
lvrdness,
Geothermal(Heating/Cooling ool" Return) Other(explain under#21 Remarks FROM TO DFSCREMONcolor soillroe4 type6 grain sbr,etc
D tz �� ft ,",•- h
4.Date Well(s)Completed:� Well ID# s Sr ft- yQ 0 fL
®c /l
5a.W Location: R &
r/ ft ft
r
Facility/Owner Name Fac"' M#(if licable) ft- h-
L'.t Cam ms o n ; ft ft.
Physical Addrow,City d Zap fL ft �'°�
21-:REMARKS
County Parcel Identification No.(PIN) _ r S'�1`tq
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —"^ 3t`p0 ��CZ�Oil
(if well field,one!atllong is sufficient)
22.Certification:
W
6.Is(are)the wells) Permanent or Temporary 3ignanue of Certified Well Contractor pate
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13 Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0206 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the -Py of this record has been provided to the well owner.
repair under#11 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 6D (D-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdierent(example-3@2000''and 2@1001 construction to the following:
10.Static water level below top of casing: J (ft) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use-+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
above,also submit one copy of this form within 30 days of completion of well
r) f '�
(i.e.auger,rotary,cable,direct push,etc.) f
construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) lz Method of test: 24c. For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: _ Amount: completion of well construction to the county,health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016